Coronary Computed Tomographic Angiography for Rapid Discharge of Low-Risk Patients With Potential Acute Coronary Syndromes - 18/09/13
Address for correspondence: Judd E. Hollander, MD, Department of Emergency Medicine, Ground Floor, Ravdin Building, Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104-4283Résumé |
Study objective |
Coronary computed tomographic (CT) angiography has excellent performance characteristics relative to coronary angiography and exercise or pharmacologic stress testing. We hypothesize that coronary CT angiography can identify a cohort of emergency department (ED) patients with a potential acute coronary syndrome who can be safely discharged with a less than 1% risk of 30-day cardiovascular death or nonfatal myocardial infarction.
Methods |
We conducted a prospective cohort study at an urban university hospital ED that enrolled consecutive patients with potential acute coronary syndromes and a low TIMI risk score who presented to the ED with symptoms suggestive of a potential acute coronary syndrome and received a coronary CT angiography. Our intervention was either immediate coronary CT angiography in the ED or after a 9- to 12-hour observation period that included cardiac marker determinations, depending on time of day. The main clinical outcome was 30-day cardiovascular death or nonfatal myocardial infarction.
Results |
Five hundred sixty-eight patients with potential acute coronary syndrome were evaluated: 285 of these received coronary CT angiography immediately in the ED and 283 received coronary CT angiography after a brief observation period. Four hundred seventy-six (84%) were discharged home after coronary CT angiography. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% confidence interval [CI] 0% to 0.8%) or sustained a nonfatal myocardial infarction (0%; 95% CI 0 to 0.8%).
Conclusion |
ED patients with symptoms concerning for a potential acute coronary syndrome with a low TIMI risk score and a nonischemic initial ECG result can be safely discharged home after a negative coronary CT angiography test result.
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| Supervising editors: Deborah B. Diercks, MD; Donald M. Yealy, MD |
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| Dr. Diercks and Dr. Yealy were the supervising editors on this article. Dr. Hollander did not participate in the editorial review or decision to publish this article. |
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| Author contributions: JEH was responsible for overall study principal investigator. JEH collated comments from other authors, prepared the final article, and takes overall responsibility for the data. JEH had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. JEH, AMC, CMM, WGB, and HIL were responsible for data collection. JEH, AMC, FSS, CMM, WGB, and HIL were responsible for analysis and interpretation of the data. JEH, FSS, CMM, and WGB were responsible for study design. JEH, AMC, FSS, and HIL wrote sections of the article. ACC, FSS, CMM, WGB, and HIL critically reviewed the article. FSS was the overall statistician for the project. HIL oversaw the radiology component of project. JEH takes responsibility for the paper as a whole. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article, that might create any potential conflict of interest. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement. Drs. Hollander, Chang, and Litt have received research funding from Siemens Medical Solutions. Dr. Litt has received an equipment grant (for cardiac CT processing research workstation not used in the study) and honoraria from Siemens Medical Solutions for speaking and for serving on the corporate advisory board for cardiac CT and MR. Dr. Litt has also served as a consultant for Medrad about contrast injector technology for cardiac CT (unrelated to this project). Dr. Hollander has been invited to attend an advisory board for Siemens Medical Solutions. |
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| Earn CME Credit: Continuing Medical Education is available for this article at: www.ACEP-EMedHome.com. |
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| Publication dates: Available online November 8, 2008. |
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| Reprints not available from the authors. |
Vol 53 - N° 3
P. 295-304 - mars 2009 Retour au numéro
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